Questions Posed by the CBO Report

1. How would a system be administered?

Under HR 1384, it would be administered by the federal government.

2. Would it include a standardized IT infrastructure?

Yes, a standardized IT infrastructure would be used.

3. Who would be eligible, and how would the system verify eligibility?

Under Section 102, the bill states:

(a) In General.—Every individual who is a resident of the United States is entitled to benefits for health care services under this Act. The Secretary shall promulgate a rule that provides criteria for determining residency for eligibility purposes under this Act.

Under Section 105, the bill states:

The Secretary shall provide for the issuance of a Universal Medicare card that shall be used for purposes of identification and processing of claims for benefits under this program. The card shall not include an individual’s Social Security number.

4. How would people enroll?

Under Section 105, the bill states:

(a) In General.—The Secretary shall provide a mechanism for the enrollment of individuals eligible for benefits under this Act. The mechanism shall—

(1) include a process for the automatic enrollment of individuals at the time of birth in the United States (or upon establishment of residency in the United States);

(2) provide for the enrollment, as of the dates described in section 106, of all individuals who are eligible to be enrolled as of such dates, as applicable; and

(3) include a process for the enrollment of individuals made eligible for health care services under section 102(b).

(b) Issuance Of Universal Medicare Cards.—In conjunction with an individual’s enrollment for benefits under this Act, the Secretary shall provide for the issuance of a Universal Medicare card that shall be used for purposes of identification and processing of claims for benefits under this program. The card shall not include an individual’s Social Security number.

5. Could people opt out?

Yes, but they would still pay their share of taxes for coverage.

6. What services would the system cover and would it cover long-term services and supports?

Under HR 1384 Improved Medicare for All, every medically necessary service, device, and drug would be covered as well as all long-term care services and supports, both in home and institutional.

7. How would the system address new treatments and technologies?

The same as traditional Medicare does now…. based on medical evidence that something new is significantly better than existing treatments & technologies.

8. What cost sharing, if any, would the plan require?


9. What role would private health insurance have?

Private insurance would be able to cover anything not covered by the public plan.

10. What role would current public programs have?

All benefits of all other public healthcare programs would be rolled into the Improved Medicare for All system. However, all VA and IHS members would have the option to continue under their respective programs, which are already government-funded programs. Tricare will be rolled into the Improved Medicare for All program. Medicaid will be rolled into the Medicare for All program, which will completely cover all benefits now covered by Medicaid.

11. How would the system pay providers and set provider payment rates?

HR 1384 would pay FFS for individual practitioners taking into account traditional Medicare rates in setting fee schedules.

The bill states:

“In establishing payment amounts for items and services under the fee schedule established under paragraph (1), the Secretary shall take into account—(A) the amounts payable for such items and services under title XVIII of the Social Security Act; and (B) the expertise of providers and value of items and services furnished by such providers.”

Soft global budgets will be negotiated with institutions (hospitals, nursing homes, etc.) Regional directors will use traditional Medicare rates as a comparative payment system in negotiating budgets with each individual institution.

The bill states:

“The regional director, on a quarterly basis, shall review whether requirements of the institutional provider’s participation agreement and negotiated global budget have been performed, and shall determine whether adjustments to such institutional provider’s payment are warranted. This review shall include consideration for additional funding necessary for unanticipated items and services for individuals with complex medical needs or market-shift adjustments related to patient value. A regional director may negotiate changes to an institutional provider’s global budget, including any adjustments to address unforeseen market- shifts related to patient volume.”

Budgets for capital and operations will be separated to ensure capital spending is done on the basis of patient need instead of provider preference.

12. How would the system purchase and determine the prices of prescription drugs?

The federal government would negotiate with pharmaceutical companies for the lowest prices, as the VA does now, but with even greater impact due to the vastly increased size of the federal portion of the market. The negotiated price would be based on comparative clinical and cost effectiveness, budget impact of providing coverage, number of similarly effective drugs, and total revenues from global sales obtained by the manufacturer for such drug. In the event of an unsuccessful negotiation at an appropriate price, the federal government would authorize the use of any patent or clinical trial data for purposes of manufacturing such drug for sale under the Medicare for All program.

13. Who would own the hospitals and employ the providers?

Hospitals and other providers would be privately owned and operated as they are now.

14. Could providers offer services that the public plan covers, to private-pay patients?

Providers who participate in the public plan cannot offer services covered by the public plan to patients paying privately. Providers who do not participate in the public plan may provide services covered by the public plan, but only if the patient understands and signs a contract stating that they understand that they could receive this service under the public plan for free, and that this contract is not made or signed in an emergency situation.

15. Could providers “balance bill” patients?

Not if they are a participating provider. For non-participating providers their services would be fully privately paid, so they can bill patients, but it would not be accurate to call it “balance” billing.

16. How would the system contain healthcare costs?

The streamlining of administration into a single payer (the federal government) will eliminate the unnecessary costs inherent in investor-owned companies with their multiple layers of bureaucracies, such as redundancies of offices, staffs, paperwork, competitive salaries and bonuses for CEOs, investor profits, and marketing. The savings from eliminating these will more than offset any need to reduce reimbursement rates, and will also eliminate current provider costs for multiple payer billing and other insurance-related billing activities that now require large clerical staffs and large amounts of practitioners’ time. Costs will also be contained by the use of soft global budgets for all institutions, including hospitals.

17. Would the system use global budgets or utilization management?

HR 1384 would set up soft global budgets for individual hospitals and other institutions. Large chains of hospitals, clinics, nursing homes, etc. would not be treated as one entity, and a separate budget would be set up with each hospital or institution within any such chain.

In this bill, global budgeting does not mean setting up one budget for an entire geographic region. Regional directors will negotiate soft global budgets with each individual institution, including hospitals, nursing homes, etc. Hospitals and other institutions will be monitored to make sure they are not spending money unnecessarily. However, the risk of cost overruns will not be shifted onto the provider. This will eliminate the incentive for providers to limit access to services, or quality of services, which is a problem inherent in shifting risk onto providers, as is now done through “capitation payment” and “Value-Based Payment” methods.

The US does not have a problem of overuse of services, and utilization management such as capitation and Value-Based Payment methods have not proven to cut costs and have resulted in increased discrimination against the most needy patients and the providers who serve them. So HR 1384 does not include “utilization management.”

18. Would the government finance the system through premiums, cost sharing, taxes, or borrowing?

HR 1384 would finance all healthcare through taxes. Because the total cost of healthcare will be lower than the current system, the new taxes will merely replace a larger amount currently being spent by households and businesses on private insurance premiums and out-of-pocket costs. We strongly advocate that the taxes be progressive, so that corporations and the ultra-wealthy will pay their fair share, and those who are low income or poor will pay little or no healthcare taxes. There will be no premiums, deductibles, co-pays, coinsurance, or any other form of cost sharing. All existing federal, state, and local government healthcare revenues would be shifted into Medicare for All, providing about two thirds of necessary funding. The final one third would be provided by new federal taxes, which would be more than offset for roughly 95% of households by the savings from the elimination of all premiums and out-of-pocket spending by individuals, employers, and employees. This would result in a significant annual savings for the average household.

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